application form for diplomatic / official visa - Indonesian Embassy in ...
application form for diplomatic / official visa - Indonesian Embassy in ...
application form for diplomatic / official visa - Indonesian Embassy in ...
You also want an ePaper? Increase the reach of your titles
YUMPU automatically turns print PDFs into web optimized ePapers that Google loves.
INDONESIAN EMBASSY<br />
38 Grosvenor Square<br />
LONDON W1K 2HW<br />
Entrance: 38a, Adam’s Row<br />
(Rear of the <strong>Embassy</strong>’s Build<strong>in</strong>g)<br />
Telephone : 020-7499 7661<br />
Fax. : 020-7491 4993<br />
Website :<br />
www.<strong>in</strong>donesianembassy.org.uk<br />
APPLICATION FORM FOR DIPLOMATIC / OFFICIAL VISA<br />
1. Full Name of applicant : ……………………………………………………… Male / Female<br />
Place and date of birth : ………………………………………………………………………….<br />
2. Present Nationality : …………………………. Nationality at birth : ……………………………<br />
3. Type and Number of Passport : ……………………………………………………………….....<br />
Place and date of issue : …………………………………………………………………………..<br />
Valid until : ……………………………………………………………………………………….<br />
4. Name(s) of family members <strong>in</strong>cluded <strong>in</strong> applicant’s passport :<br />
Full Name Relationship M / F Place & Date of birth<br />
……………………………………………..<br />
…………………….……………………….<br />
…………………….……………………….<br />
…………………….……………………….<br />
…………………….……………………….<br />
……………..<br />
……………..<br />
……………..<br />
……………..<br />
……………..<br />
……...<br />
……...<br />
……...<br />
……...<br />
……...<br />
……………………….<br />
……………………….<br />
……………………….<br />
………………………..<br />
……………………….<br />
5. Name of Spouse : ………………………………………………………………………………...<br />
Present Nationality : ………………………… Nationality at birth : …………………………….<br />
Profession : ……………………………………………………………………………………….<br />
Name and Address of Employer (if applicable) : ………………………………………………...<br />
…………………………………………………………………………………………………….<br />
6. Present Address and Telephone Number :<br />
………………………………………………………..<br />
…………………………………………………………………………………………………….<br />
7. A. Work related details <strong>in</strong> UK / Ireland :<br />
Occupation : ………………………………………………………………………………….<br />
Employer : ………………………………………………………………………………….<br />
Employer’s Address and Telephone number : ……………………………………………….<br />
………………………………………………………………………………………………...<br />
B. In Indonesia :<br />
Name and Address of Company / Employer : ………………………………………………..<br />
………………………………………………………………………………………………...<br />
Telephone/Fax number : ……………………………………………………………………...<br />
8. Purpose of journey <strong>in</strong>to Indonesia : ………………………………………………………………<br />
9. Duration of stay <strong>in</strong> Indonesia :<br />
……………………………………………………………………<br />
10. Port and Date of Entry : ………………………………………………………………………….<br />
11. Name of carrier (Air / Sea) : ……………………………………………………………………..<br />
12. Other <strong>in</strong><strong><strong>for</strong>m</strong>ation : ……………………………………………………………………………….
13. Entry Visa(s) granted to applicant :<br />
Type of Visa : ……………………………………………………………………………………<br />
Number of Visa(s) : ………………………………………………………………………………<br />
Place and Date of issue : …………………………………………………………………………<br />
14. The follow<strong>in</strong>g questions can be answered with a simple “Yes” or “No”. If the answer is “Yes”,<br />
please give explanation.<br />
Has applicant ever committed crim<strong>in</strong>al offences ?<br />
………………………………………………..<br />
Has applicant’s request <strong>for</strong> <strong>visa</strong> to enter Indonesia ever been refused ?<br />
………………………….<br />
Has applicant ever been to Indonesia ?<br />
…………………………………………………………...<br />
If Yes, where, when and <strong>for</strong> what purpose : ……………………………………………………...<br />
…………………………………………………………………………………………………….<br />
Has applicant ever been ordered to leave Indonesia ? ……………………………………………<br />
I have completed this questionnaires truthfully to the best of my knowledge and understand that I<br />
can be expelled from Indonesia if the <strong>in</strong><strong><strong>for</strong>m</strong>ation I have given proved false.<br />
I understand that, even though a Visa is granted, the authorization to enter Indonesia rema<strong>in</strong>s at the<br />
discretion of the Immigration Office <strong>in</strong> Indonesia.<br />
I understand further that the <strong>visa</strong> will become <strong>in</strong>valid if my entry <strong>in</strong>to Indonesia does not take place<br />
with<strong>in</strong> the period specified on my <strong>visa</strong>.<br />
Photograph of applicant<br />
Place : ………………… Date : …………………<br />
Signature of applicant :<br />
(the same as <strong>in</strong> passport)<br />
Full name pr<strong>in</strong>ted :<br />
FOR OFFICIAL USE ONLY<br />
SP. No. : ……………………<br />
1. Telah diberikan Visa atas ij<strong>in</strong> Dirjenim No. …………………………………..…………………<br />
Tanggal : ………………………………………………………………………………………….<br />
Nomor Visa : ……………………………………………………………………………………..<br />
Lamanya diij<strong>in</strong>kan t<strong>in</strong>ggal di Indonesia :…………………………………………………………<br />
Tanggal Pemberian Visa : ………………………………………………………………………..<br />
2. Diajukan kepada Direktur Jenderal Imigrasi untuk mendapatkan keputusannya.<br />
London, tgl. ……………………...<br />
Paraf,
Change language